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BackgroundCommon, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.Research questionCan we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?Study design and methodsA panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.ResultsIn eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.InterpretationWe propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Purpose Intravenous maintenance fluid therapy (IV-MFT) prescribing in acute and critically ill children is very variable among pediatric health care professionals. In order to provide up to date IV-MFT guidelines, the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) undertook a systematic review to answer the following five main questions about IV-MFT: (i) the indications for use (ii) the role of isotonic fluid (iii) the role of balanced solutions (iv) IV fluid composition (calcium, magnesium, potassium, glucose and micronutrients) and v) and the optimal amount of fluid. Methods A multidisciplinary expert group within ESPNIC conducted this systematic review using the Scottish Intercollegiate Guidelines Network (SIGN) grading method. Five databases were searched for studies that answered these questions, in acute and critically children (from 37 weeks gestational age to 18 years), published until November 2020. The quality of evidence and risk of bias were assessed, and meta-analyses were undertaken when appropriate. A series of recommendations was derived and voted on by the expert group to achieve consensus through two voting rounds. Results 56 papers met the inclusion criteria, and 16 recommendations were produced. Outcome reporting was inconsistent among studies. Recommendations generated were based on a heterogeneous level of evidence, but consensus within the expert group was high. 'Strong consensus' was reached for 11/16 (69%) and 'consensus' for 5/16 (31%) of the recommendations. Conclusions Key recommendations are to use isotonic balanced solutions providing glucose to restrict IV-MFT infusion volumes in most hospitalized children and to regularly monitor plasma electrolyte levels, serum glucose and fluid balance., Author(s): David W. Brossier [sup.1], Lyvonne N. Tume [sup.2], Anais R. Briant [sup.3], Corinne Jotterand Chaparro [sup.4] [sup.5], Clémence Moullet [sup.4], Shancy Rooze [sup.6], Sascha C. A. T. Verbruggen [sup.7], [...]

Background: Despite increasing evidence of the potential inaccuracy and unwarranted practice of regular GRV measurement in critically in adults, this practice persists within the United Kingdom. Aim: To explore adult intensive care nurses' decision‐making around the practice of GRV measurement to guide enteral feeding. Study Design: A cross‐sectional 16 item electronic survey in four adult intensive care units (ICUs) in England and Wales. Results: Two hundred and seventy‐three responses were obtained across four ICUs with acceptable response rates for most [Unit 1 74 /127 = 58.2%; Unit 2 87/129 = 67.4%; Unit 3 77/120 = 64.1%; Unit 4 35/168 = 20.8%]. Most (243/273 (89%) reported measuring GRV 4–6 hourly, with most (223/273 82%) reporting that the main reason was to assess feed tolerance or intolerance and 37/273 (13.5%) saying their unit protocol required it. In terms of factors affecting decision‐making, volume obtained was the most important factor, followed by the condition of the patient, with aspirate colour and appearance less important. When asked how they would feel about not measuring GRV routinely, the majority (78.2%) of nurses felt worried (140/273 = 51.2%) or very worried (74/273 = 27%). Conclusions: Factors affecting the nurses' decision‐making around GRV were based largely on fear of risk (around vomiting and pulmonary aspiration) and compliance with unit protocols. Relevance to Clinical Practice: Despite increasing evidence suggesting it is unnecessary, nurses' beliefs around the value of this practice persist and it continues to be embedded into unit protocols around feeding. [ABSTRACT FROM AUTHOR]

Background: Survival from pediatric critical illness in high‐income countries is high, and the focus now must be on optimizing the recovery of survivors. Muscle mass wasting during critical illness is problematic, so identifying factors that may reduce this is important. Therefore, the aim of this study was to examine the relationship between quadricep muscle mass wasting (assessed by ultrasound), with protein and energy intake during and after pediatric critical illness. Methods: A prospective cohort study in a mixed cardiac and general pediatric intensive care unit in England, United Kingdom. Serial ultrasound measurements were undertaken at day 1, 3, 5, 7, and 10. Results: Thirty‐four children (median age 6.65 [0.47–57.5] months) were included, and all showed a reduction in quadricep muscle thickness during critical care admission, with a mean muscle wasting of 7.75%. The 11 children followed‐up had all recovered their baseline muscle thickness by 3 months after intensive care discharge. This muscle mass wasting was not related to protein (P = 0.53, ρ = 0.019) (95% CI: −0.011 to 0.049) or energy intake (P = 0.138, ρ = 0.375 95% CI: −0.144 to 0.732) by 72 h after admission, nor with severity of illness, highest C‐reactive protein, or exposure to intravenous steroids. Children exposed to neuromuscular blocking drugs exhibited 7.2% (95% CI: −0.13% to 14.54%) worse muscle mass wasting, but this was not statistically significant (P = 0.063). Conclusion: Our study did not find any association between protein or energy intake at 72 h and quadricep muscle mass wasting. [ABSTRACT FROM AUTHOR]

Background Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions., Author(s): Lyvonne N. Tume [sup.1] [sup.2], Frederic V. Valla [sup.3], Koen Joosten [sup.4], Corinne Jotterand Chaparro [sup.5] [sup.6], Lynne Latten [sup.7], Luise V. Marino [sup.8], Isobel Macleod [sup.9], Clémence Moullet [...]

Background: Premature neonates often experience feeding difficulties during their hospital stay, and evidence‐based interventions have been shown to improve feeding outcomes. Aim: This study investigated whether an infant‐cue based nurse educational feeding bundle accelerates the achievement of independent oral feeding in neonates in a neonatal intensive care unit. Study Design: A quality improvement study with a pre, during and post intervention test design. All premature neonates admitted to the unit were eligible. The feeding programme included a four‐month nurse training module and nurse coaching. Results: A hundred and twenty‐five nurses or nurse assistants attended the programme and 706 neonates were included. The median time to independent oral feeding (IOF) was 40, 36 and 37 days, respectively, for pre, during and post intervention. The reduction in time to IOF observed during the post‐intervention period compared with the baseline period was significant (HR = 1.32, CI 95%: 1.01–1.74). No difference was noted in the length of hospital stay between the three study periods. Conclusions: An infant‐cue based nurse educational feeding bundle can promote earlier achievement of IOF in preterm neonates. Relevance to Clinical Practice: This quality improvement study demonstrates the impact that a nurse‐driven intervention in neonatal care can have on improving practice. Feeding interventions involve the early introduction of oral feeding, non‐nutritive sucking (NNS), and oral motor stimulation, and should be individualized for each neonate. These individualized feeding interventions applied by all nurses and assistant nurses, can facilitate the achievement of earlier independent oral feeding in preterm infants and should be included in neonatal critical care nurse education programs. [ABSTRACT FROM AUTHOR]

Objective: To describe and discuss a 2-step methodology developed to select a reference society that provides Dietary Reference Values (DRV) for national implementation and to illustrate its application in Switzerland with one macronutrient and one micronutrient. Design: During Step 1, we searched and compared DRV and methodologies used to define DRV from eight European societies for seven selected nutrients. We repeated this procedure during Step 2 for DRV from two preselected societies for forty-four nutrients. Setting: The 2-step methodology applied here for Switzerland may be used in other countries. Participants: The research team commissioned six external experts from three linguistic regions of Switzerland, who provided their opinions through two online surveys, individual interviews and a focus group. Results: After Step 1, we excluded five societies because of old publication dates, irrelevant publication languages for Switzerland, difficulty in accessing documents, or because their DRV were mainly based on another society. After Step 2, the two societies were qualified based on the analysis of the values and methodologies used. The need for free and easily accessible scientific background information favoured the European Food Safety Authority (EFSA). We chose alternative societies for nine nutrients for the overall population or subgroups and for the elderly. Conclusions: To manage heterogeneous and complex data from several societies, adopting a 2-step methodology including fewer nutrients and more societies during Step 1, and fewer societies but all nutrients in Step 2, was very helpful. With some exceptions, we selected EFSA as the main society to provide DRV for Switzerland. [ABSTRACT FROM AUTHOR]

The authors discuss the importance for nurses to understand basic statistics. They talk about the benefits of understanding basic statistics, importance of statistical skills for research-active nurses who have the motivation to become research leaders and chief investigators, and recommendation for urgent changes to undergraduate nursing education in higher education institutions where statistics are not already taught to nurses.